F0842

E

Failure to Document Resident-to-Resident Verbal Abuse Incidents in Medical Records

Bement, Illinois Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records related to allegations of resident-to-resident verbal abuse. One resident (R18) reported that her former roommate (R15) yelled, cursed, and repeatedly used offensive language toward her about a week prior, causing her to feel afraid and reluctant to identify the roommate for fear of retaliation. A CNA (V9) corroborated that sometime the previous week, R15 was loudly yelling at R18, that R18 was visibly upset, and that the two residents were arguing back and forth. The CNA stated that an agency staff member notified an unidentified nurse, and that the CNA notified the Administrator/Abuse Prevention Coordinator (V1) the same day after calming the residents.

Despite these reports, there was no contemporaneous documentation of the verbal abuse allegations or related monitoring in either R15’s or R18’s medical records. The facility’s initial report to the Illinois Department of Public Health (IDPH), dated 3/10/26 and written by V1, shows that V9 had reported an incident from approximately one week earlier and that a psychotherapist/LCSW (V7) reported on 3/9/26 hearing R15 call R18 a derogatory name, after which the residents were moved to separate rooms. The IDPH report also records that R18 described feeling fearful of R15, citing the earlier name-calling incident that she had been too afraid to report at the time, and that R18 stated R15 regularly used offensive language and a confrontational tone.

V1 acknowledged that when V7 reported hearing R15 call R18 a derogatory name, V1 viewed it more as a grievance, did not enter it on the grievance log, did not treat it as a potential abuse issue, and did not document anything in either resident’s chart. Review of the electronic medical records for R15 and R18 confirmed that neither social services (V10, Social Service Director; V7, LCSW/Psychotherapist) nor nursing staff documented the abuse allegations or any monitoring on the dates the incidents were reported by staff or surveyors. Late social service notes for both residents were created on 3/12/26, backdated to 3/9/26, indicating that the Administrator and an NP were notified that one resident called the other a name and to monitor for further behaviors or anxiety, but these notes did not capture the earlier incident reported by the CNA or the subsequent allegations reported on 3/9/26 and 3/10/26. These omissions occurred despite facility policies requiring that all incidents, allegations, or suspicions of abuse, and all incidents, accidents, or changes in condition, be documented in the resident’s medical record.